CMS Measure ID: #128
Collection Type: CQM
Reporting Frequency: Most Recent Visit(with 12 mo. exception)
Outcome: No
High Priority: No
NQS Domain: Community, Population and Public Health
Measure Age: > 2 years
Instructions
There is no diagnosis associated with this measure. This measure is to be submitted a minimum of once per performance period for patients seen during the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided at the time of the qualifying visit and the measure-specific denominator coding. The BMI may be documented in the medical record of the provider or in outside medical records obtained by the provider. If the most recent documented BMI is outside of normal parameters, then a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter. The documented follow-up plan must be based on the most recent documented BMI outside of normal parameters, example: “Patient referred to nutrition counseling for BMI above or below normal parameters” (See Definitions for examples of follow-up plan treatments). If more than one BMI is submitted during the measurement period, the most recent BMI will be used to determine if the performance has been met. Review the exclusions and exceptions criteria to determine those patients that BMI measurement may not be appropriate or necessary.
Measure Submission Type:
The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.
Description
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if the most recent BMI was outside of normal parameters.
2023 Benchmarks (from 2021 CMS data)
Registry
Topped out: Yes
Capped at 7: No
Decile 0: 0 – 2.27
Decile 1: 2.28 – 31.81
Minimum: 31.82 – 64.93
Decile 3: 64.94 – 85.32
Decile 4: 85.33 – 94.61
Decile 5: 94.62 – 98.34
Decile 6: 98.35 – 99.71
Decile 7: 99.72 – 99.99
Decile 10: 100 – 100
eCQM
Topped out: No
Capped at 7: No
Minimum: 0 – 23.94
Decile 3: 23.95 – 29.01
Decile 4: 29.02 – 35.83
Decile 5: 35.84 – 44.98
Decile 6: 44.99 – 57.81
Decile 7: 57.82 – 73.46
Decile 8: 73.47 – 86.07
Decile 10: 95.32 – 100
Decile 9: 86.08 – 95.31
Denominator
All patients aged 18 and older on the date of the encounter with at least one eligible encounter during the measurement period
Definition:
Not Eligible for BMI Screening or Follow-Up Plan (Denominator Exclusions) – A patient is not eligible if one or more of the following reasons are documented:
• Patients receiving palliative or hospice care on the date of the current encounter or any time prior to the current encounter
• Patients who are pregnant on the date of the current encounter or any time during the measurement period prior to the current encounter
DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 96156, 96158, 97161, 97162, 97163, 97165, 97166, 97167, 97802, 97803, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99236, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99424, 99491, D7111, D7140, D7210, D7220, D7230, D7240, D7241, D7250, D7251, G0101, G0108, G0270, G0271, G0402, G0438, G0439, G0447, G0473
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02, FQ, 93
WITHOUT
Place of Service (POS): 12
AND NOT
DENOMINATOR EXCLUSIONS:
Documentation stating the patient has received or is currently receiving palliative or hospice care: G9996
OR
Documentation of patient pregnancy anytime during the measurement period prior to and including the current encounter: G9997
Numerator
Patients with a documented BMI during the encounter or during the previous twelve months AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the encounter
Definitions:
Normal BMI Parameters – Age 18 years and older BMI >= 18.5 and < 25 kg/m2
BMI – Body mass index (BMI) is a number calculated using the Quetelet index: weight divided by height squared (W/H2) and is commonly used to classify weight categories. “BMI” can be calculated using:
Metric Units: BMI = Weight (kg) / (Height (m) x Height (m))
OR
English Units: BMI = Weight (lbs) / (Height (in) x Height (in)) x 703
Follow-Up Plan – Proposed outline of treatment to be conducted as a result of a BMI outside of normal parameters. A follow-up plan may include, but is not limited to:
-
Documentation of education
-
Referral (for example a Registered Dietitian Nutritionist (RDN), occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional, or surgeon), for lifestyle/behavioral therapy
-
Pharmacological interventions
-
Dietary supplements
-
Exercise counseling
-
Nutrition counseling
Patients with a Documented Reason for Not Screening BMI (Denominator Exception) –
Patient Reason:
-
Patients who refuse measurement of height and/or weight on the date of the current encounter or any time during the measurement period prior to the current encounter
OR
Medical Reason:
-
Patients with a documented medical reason for not documenting BMI such as patients in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status.
Patients with a Documented Reason for Not Documenting a Follow-up Plan for BMI Outside Normal Parameters (Denominator Exception) –
Medical Reason(s):
-
Patients (e.g., elderly patients 65 years of age or older) for whom weight reduction/weight gain would complicate other underlying health conditions such as illness or physical disability, mental illness, dementia, confusion, or nutritional deficiency such as vitamin/mineral deficiency; patients in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status
Numerator Instructions:
-
Height and Weight – An eligible clinician or their staff is required to measure both height and weight. Both height and weight must be measured within twelve months of the current encounter. Self-reported values cannot be used.
-
The BMI may be documented in the medical record of the provider or in outside medical records obtained by the provider.
-
If more than one BMI is reported during the measurement period, the most recent BMI will be used to determine if the performance has been met.
-
-
Follow-Up Plan – If the most recent documented BMI is outside of normal parameters, then a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter. The documented follow-up plan must be based on the most recent documented BMI, outside of normal parameters, example: “Patient referred to nutrition counseling for BMI above or below normal parameters”. (See Definitions for examples of follow-up plan treatments).
-
Performance Met for G8417 & G8418 –
-
If the provider documents a BMI and a follow-up plan for a BMI outside normal parameters at the current encounter OR
-
If the patient has a documented BMI within the previous twelve months of the current encounter, the provider documents a follow-up plan for a BMI outside normal parameters at the current encounter OR
-
If the patient has a documented BMI within the previous twelve months of the current encounter AND the patient has a documented follow-up plan for a BMI outside normal parameters within the previous twelve months of the current encounter
-
Numerator Options:
Performance Met: BMI is documented within normal parameters and no follow-up plan is required (G8420)
OR
Performance Met: BMI is documented as above normal parameters and a follow-up plan is documented (G8417)
OR
Performance Met: BMI is documented as below normal parameters and a follow-up plan is documented (G8418)
OR
Denominator Exception: BMI not documented due to medical reason OR patient refusal of height or weight measurement (G2181)
OR
Denominator Exception: BMI is documented as being outside of normal parameters, follow-up plan is not completed for documented medical reason (G9716)
OR
Performance Not Met: BMI not documented and no reason is given (G8421)
OR
Performance Not Met: BMI documented outside normal parameters, no follow-up plan documented, no reason given (G8419)